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Diagnostic Criteria for Use in Psychiatric Research

.JohnP . Feighner, MD; Eli Robins, MD; Samuel B. Guze, MD; Eobert A. Woodrmff,Jr., MD; George Winokur, MD; and Rodrigo M u m , MD, S t . Louis

Diagnostic criteria for 14 psychiatric illnesses (and for secondary deprnssion) along with the validating r,*idpnce for these diagnostic cate,/,,ries comes from workers outside ,,ti,. group as weU as from those within; i t consists of studies o f both outpatients and inpatients, o f family studies, and of follow-up studies. These criteria are the most ~ficient currently avazhble; howuzler, it is expected that the criteria be tested and not be considered a Atutl, closed system. It is expected t h r r l the criteria uill change as vari~3 illnesses are studied by different gr~mps. Such criteria provide a f mmework for comparison of data gathered in different centers, and serve to promote communication between investigators.

Tms communication presents specific diagnostic criteria for those


~ c ! i ~ 1)sychiatric it illnesses

that have

bcxm sufficiently validated by precise

clinical description, follow-up, and family studies to warrant their use in research as well as in clinical practice. These criteria are not intended as final for any illness. The criteria represent a distillation of our clinical research experience, and of the exptbriences of others cited in the ktwwwes. This communication is nleatlt to provide common ground 'or different research groups so that diagnostic definitions can be emended constructively as further Studies are completed. The use of formal diagnostic criteria by a number of groups, regardless of whether their interests are clinical, !,schodynamic, pharmacologic, chemleal. ncuropsychological, or neuro-

physiological, will result in a solution of the problem of whether patients described by different groups are comparable. This first and crucial taxonomic step should expedite psychiatric investigation. Diagnosis has functions as important in psychiatry a s elsewhere in medicine. Psychiatric diagnoses based on studies of natural history permit prediction of course and outcome, allow planning for both immediate and long-term treatment, and make communication possible between psychiatrists and other physicians, as well as among psychiatrists themselves. Such functions are of obvious importance in research.1" In contrast to the American Psychiatric Association Diagnostic and Statistical Manual o f Mental Disorders (DSM-II), in which the diagnostic classification is based upon the "best clinical judgement and experience" of a committee and its consultants, this communication will present a diagnostic classification validated primarily by follow-up and family studies. The following criteria for establishing diagnostic validity in psychiatric illness have been described elsewhere and may be divided into five phase^.^

The Five Phases


1 . Clinical Description.

..

for publication April 9, 1971. the Denartment of Psychiatry. Waehuniversity School of Medicine, St. Louis. Feiahner 1s currently with the Department 0 : ~ ~ , . ~ h ~ of ~ California, ~ ~ , Sari olego. La Jolla and M~~~~ ~ ~ and ~ ~ ~ d i mLC~7ter. San Diego. Calif. "'print requeata to Department of Faychi*ashinnton University School of Medicine. RobAuduhon Louis 63110
-'.c'uted

In general, t h e first step is to describe t h e clinical picture of the disorder. This may be a single striking clinical feature o r a combination of clinical features thought to be associated with one another. Race, sex, age a t onset, precipitating factors, and other items may be used t o define the clinical picture more precisely. The clinical picture t h u s does not include only symptoms. 2. Laboratmy Studies. Included among laboratory studies a r e chemical, physiological, radiological, and anatomical (biopsy and autopi SY) findings. ~ ~ Certain l psychological tests. . -- . - , when . . - -. shown . . . . . to - be .- reliable and may also be considered laboratory studies i n this context. Laboratory findings a r e generally

more reliable, precise, and reproducible than a r e clinical descriptions. When consistent with a defined clinical picture they permit a more refined classification. Without such a defined clinical picture, their value may be considerably reduced. Unfortunately, consistent and reliable laboratory findings have not yet been demonstrated in t h e more common psychiatric disorders. 3. Delimitation From Other Disorders. Since similar clinical features and laboratory findings may be seen in patients suffering from different disorders (eg, cough and blood in the sputum in lobar pneumonia, bronchiectasis, and bronchogenic carcinoma), i t is necessary to specify exclusion criteria so t h a t patients with other illnesses a r e not included in the group to be studied. These criteria should also permit exclusion of borderline cases and doubtful cases (an undiagnosed group) so that the index group may be a s homogeneous as possible. 4. Follow-up Study. The purpose of the follow-up study is to determine whether or not the original patients a r e suffering from some other defined disorder that could account f o r the original clinical picture. If they a r e suffering from anothe r such illness, this finding suggests t h a t t h e original patients did not comprise a homogeneous group and t h a t it i s necessary to modify the diagnostic criteria. I n the absence of known etiology o r pathogenesis, which is true of the more common psychiatric disorders, marked differences in outconie, such a s between complete recovery and chronic illness, suggest that the group is not homogeneous. This latter point is not a s compelling in suggesting diagnostic heterogeneity as is the finding of a change in diagnosis. The same illness may have a variable prognosis, but until we know more about t h e fundamental nature of the common psychiatric illnesses, marked differences in outcome should be regarded as a challenge to the validity of the original diagnosis. 5 . Family Study. Most psychiatric illnesses have been shown to r u n in families, whether the investigations were designed to study hereditarv o r environnlental causes. independent of the questlon of etiology, therefore, the firldillg of a n increased prevalence of the same disor-

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der among close relatives of the original patients strongly indicates that one is dealing with a valid entity. While no psychiatric syndrome has yet been fully validated by a complete series of steps, a great deal of work has been published indicating that substantial validation i s possible. This communication is a summary of that work in the form of specific diagnostic criteria. The studies of validation for each illness are cited. In addition, we in this department have carried out a study of interrater reliability and validation of reliability with an 18-month follow-up study of 314 psychiatric emergency room patients (to be published) as well as a seven-year follow-up study of 87 psychiatric inpatients (to be published), each of whom was interviewed personally and systematically. There were four different raters in the emergency room study. Agreement ranged from 86% to 95% about diagnosis with diagnostic criteria similar to those outlined in this report. There were two different raters in the inpatient study ; reliability between those raters was 92%. In the emergency room study and in the inpatient study, validity, as determined by correctly predicting diagnosis at follow-up by criteria such as those of this report, was 93% and 92%, respectively. Not only are specific criteria necessary for each diagnosis, but criteria are also needed for scoring individual symptoms as positive. The following criteria have been used for this purpose. (1) The patient saw a physician (includes chiropractor, naturopath, healer, etc) for the symptom. (2) The symptom was disabling enough to interfere with the patient's usual routine. ( 3 ) The symptom led the patient to take medication on more than one occasion. ( 4 ) The examining physician believes that, because of its clinical importance, the symptom should be scored positive even though the aforementioned criteria were not present; eg, a spell of blindness 58

lasting a few minutes that the patient minimizes, or hallucinations or delusions which the patient does not recognize as pathological, and which did not disrupt the patient's usual routine. (5) Symptoms are not scored positive if they can be explained by a known medical disease of the patient (this does not apply to organic brain syndrome and mental retardation). It will be apparent below that certain diagnoses are mutually exclusive (primary affective disorders and schizophrenia), while others may be made in the same patient (antisocial personality disorder with alcoholism or drug dependency ; hysteria or anxiety neurosis with secondary depression). More work will be necessary before the full significance of various diagnostic combinations becomes evident. I t should also be clear that any of the diagnoses may be further subdivided according to various clinical, demographic, or other variables. For example, primary depression may be divided into psychotic and nonpsychotic, bipolar and unipolar, early onset and late onset. Simiiarly, schizophrenia may be subdivided into paranoid, hebephrenic, and catatonic subtypes. Diagnostic Criteria

fatigability, tiredness. ( 4 ) Agitation or retardation. (5) Loss of interest in usual activities, or decrease in sexual drive. (6) Feelings of self-reproach or guilt (either may be delusional). ( 7) Complaints of or actually diminished ability t o think or concentrate, such as slow thinking or mixed-up thoughts. (8) Recurrent thoughts of death or sui-3 cide, including thoughts of wishing to be dead. C. A psychiatric illness lasting at least one month with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic,$ neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome. ( Patients with life-threatening or incapacitating medical illness preceding and paralleling the depression do not receive the diagnosis of primary depression.) Mania.-For a diagnosis of ma nia, A through C are required. A. Euphoria or irritability. B. At least three of the followingGi symptom categories must also be". present. (1) Hyperactivity cludes motor, social, and sexual

Primary Affective D i ~ o r d e r s . ~ - l ~ -Depression.-For a diagnosis of C. A psychiatric illness lasting at.. depression, A through C are releast two weeks with no preexisting quired. psychiatric conditions such as schiz-. A. Dysphoric mood characterized ophrenia, anxiety neurosis, phobic by symptoms such as the following : neurosis, obsessive compulsive neu- , depressed, sad, blue, despondent, hopeless, "down in the dumps," irpendency, antisocial persona ritable, fearful, worried, or discouraged. B. At least five of the following ganic brain syndrome. criteria are required for "definite" There are patients who fulfi depression; four are required for the above criteria, but also have "probable" depression. (1) Poor apmassive or peculiar alteration petite or weight loss (positive if 2 perception and thinking as a m lb a week or 10 Ib or more a year jor manifestation of their illnes& when not dieting). (2) Sleep diffiThese patients are considered culty (include insomnia or hypersome to have a "schizophreniform' somnia). (3) Loss of energy, eg, Diagnostic Criteria for Psychiat~ic Research/Feighner

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or "atypical" psychosis, ie, an illness of acute onset (less than six) months), in a patient with good , premorbid psychosocial adjustment, with prominent delusions and halluinations in addition to the affective symptoms. Clinical studies of this disorder indicate that from 60% to 00% of cases have a remitting illne& and return to premorbid levels of psychosocial adjustment with a longitudinal course consistent with primary affective disorder.17-22 The remaining 10% to 40% have a chronic illness consistent with schiz.~phrenia.These patients are, therefore, classified as having an undiagnowd psychiatric disorder and are nor included in either primary affective disorder or schizophrenia. , Secondary Affective Disorders.Secondary depression, "definite" or "probable," is defined in the same way as primary depression, except that it occurs with one of the fol; w i n g : (1) A preexisting non~3'eotive psychiatric illness which rsiay or may not still be present. (2) A life-threatening or incapacitating medical illness which precedes and parallels the symptom$ of depresY ion. Schizophrenia.l7-"-For a diagnosis of schizophrenia A through C are required. A. Both of the following are necwsary: (1) A chronic illness with a! least six months of symptoms to the index evaluation without return to the premorbid level of ~~ychosocial adjustment. (2) Absence of a period of depressive or manic. symptoms sufficient to qualify for affective disorder or probable affective disorder. B. The patient must have a t least m e of the following : (1) Delusions o t .4allucinations without significant pf'l'dexity or disorientation associdtid with them. (2) Verbal production that makes communication difficult because of a lack of logical or understandable organization. (In the presence of muteness the diagGSKdeec'ision must be deferred.) 'We recognize that many patients

or

with schizophrenia have a characteristic blunted o r inappropriate affect; however, when i t occurs in mild form, interrater agrement is difficult to achieve. We believe that, on the basis of presently available information, blunted affect occurs rarely or not a t all in the absence of B-1 or B-2.) C. At least three of the following manifestations must be present for a diagnosis of "definite" schizophrenia, and two for a diagnosis of "probable" schizophrenia. ( 1 ) Single. (2) Poor premorbid social adjustment or work history. (3) Family history of schizophrenia. (4) Absence of alcoholism or drug abuse within one year of onset of psychosis. (5) Onset of illness prior to age 40. Anxiety Neurosi~.~~-For a diagnosis of anxiety neurosis, A through D are required. A. The following manifestations must be present: (1) Age of onset prior to 40. (2) Chronic nervousness with recurrent anxiety attacks manifested by apprehension, fearfulness, or sense of impending doom, with a t least four of the following symptoms present during the majority of attacks: (a) dyspnea, ( b ) palpitations, ( c ) chest pain or discomfort, ( d ) choking or smothering sensation, (e) dizziness and (f)paresthesfas: B. The anxiety attacks are essential to the diagnosis and must occur a t times other than marked physical exertion or life-threatening situations, and in the absence of medical illness that could account for symptoms of anxiety. There must have been a t least six anxiety attacks, each separated by a t least a week from the others. C. In the presence of other psychiatric illness(es) this diagnosis is made only if the criteria described in A and B antedate the onset of the other psychiatric illness by a t least two years. D. The diagnosis of probable anxiety neurosis is made when a t least two symptoms listed in A-2

are present, and the other criteria are fulfilled. Obsessive Compulsive Neurosis.33.34-For a diagnosis of obsessive compulsive neurosis, both A and B are required. A. Manifestations 1 and 2 are required. (1) Obsessions or compulsions are the dominapt symptoms. They are defined as recurrent or persistent ideas, thoughts, images, feelings, impulses, or movements, which must be accompaqied by a sense of subjective compulsion and a desire to resist the event, the event being recognized by the individual as foreign to his personality or nature, ie, "ego-alien." (2) Age of onset prior to 40. B. Patients with primary or probable primary affective disorder, or with schizophrenia or probable schizophrenia, who manifest obsessive-compulsive features, do not receive the additional diagnosis of obsessive compulsive neurosis. a diPhobic Neurosis.~~~3~--For agnosis of phobic neurosis, both A and B are required. A. Manifestations 1 and 2 are required. (1) Phobias are the dominant symptoms. They are defined as persistent and recurring fears which the patient tries to resist or avoid and a t the same time considers unreasonable. (2) Age of onset prior to 40. B. Symptoms of anxiety, tension, nervousness, and depression may accompany the phobias ; however, patients with another definable psychiatric illness should not receive the additional diagnosis of phobic neurosis. H~steria.3~-~~-F aodiagnosis r of hysteria, both A and B are required. A. A chronic or recurrent illness beginning before age 30, presenting with a dramatic, vague, or complicated medical history. B. The patient must report a t least 25 medically unexplained symptoms for a "definite" diagnosis and 20 to.24 symptons for a "yrobablewdiagnosis in a t least nine of the
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following groups.
Group 1 Headaches Sickly majority of life Group 2 Blindness Paralysis Anesthesia Aphonia Fits or convulsions Unconsciousness Amnesia Deafness Hallucinations Urinary retention Trouble walking Other unexplained "neurological"symptoms Group 3 Fatigue Lump in throat Fainting spells Visual blurring Weakness Dysuria Group 4 Breathing difficulty Palpitation Anxiety attacks Chest pain Dizziness Group 5 Anorexia Weight loss Marked fluctuations in weight Nausea Abdominal bloating Food intolerances Diarrhea Constipation Group 6 Abdominal pain Vomiting Group 7 Dysmenorrhea Menstrual irregularity Amenorrhea Excessive bleeding Group 8 Sexual indifference Frigidity Dyspareunia Other sexual difficulties Vomiting all nine months of pregnancy at least once, or hospitalization for hypernlesis gravidarum Group 9 Back pain Joint pain Extremity pain Burning pains of the sexual organs, mouth, or rectum

Other bodily pains Group 10 Nervousness Fears Depressed feelings Need to quit working, or inability to carry on regular duties because of feeling sick Crying easily Feeling life was hopeless Thinking a good deal about dying Wanting to die Thinking about suicide Suicide attempts

Antisocial Personality Disorder.4.41-A chronic o r recurrent disorder with the appearance of a t least one of the following manifestations before age 15. A minimum of five manifestations are required for a "definite" diagnosis, and four are required for a "probable" diagnosis. A. School problems a s manifested by any of the following: truancy (positive if more than once per year except for the last year in school), suspension, expulsion, or fighting that leads to trouble with teachers or principals. B. Running away from home overnight while living in parental home. C. Troubles with the police as manifested by any of the following: two or more arrests for nontraffic offenses, four o r more arrests (including tickets only) for moving traffic offenses, or a t least one felony conviction. D. Poor work history a s manifested by being fired, quitting without another job to go to, or frequent job changes not accounted for by normal seasonal or economic fluctuations. E. Marital difficulties manifested by any of the following: deserting family, two or more divorces, frequent separations due to marital discord, recurrent infidelity, recurrent physical attacks upon spouse, or being suspected of battering a child. F. Repeated outbursts of rage or fighting not on the school premises : if prior to age 18 this must occur a t

least twice and lead to difficulty* with adults; after age 18 this must' occur a t least twice, or if a weaporr" (eg, club, knife, or gun) is used' only once is enough to score thi% category positive. G. Sexual problems a s manifeste by any of the following: prostitu, tion (includes both heterosexual ant# homosexual activity), pimping, mord than one episode of venereal disease,! or flagrant promiscuity. H. Vagrancy or wanderlust, eg' a t least several months of wand ing from place to place with prearranged plans. I. Persistent and repeated lying or using an alias. Al~oholism.~2-*6-A "definite" diagnosis is made when symptoms occur in a t least three of the four! following groups. A "probable" di-1 agnosis is made when symptoms oc-j cur in only two groups. A. Group One : (1) Any manifes-? tation of alcohol withdrawal such as{ tremulousness, convulsions, halluci-"I nations, or delirium, ( 2 ) History of medical complications, eg, cirrhosis,.l gastritis, pancreatitis, myopat'ny, polyneuropathy, Wernicke-Korsak-"; off's syndrome. (3) Alcoholic blackouts, ie, amnesic episodes during heavy drinking not accounted for by, head trauma. (4) Alcoholic binges or benders (48 hours or more of drinking associated with default of. usual obligations: must have oc-+ curred more than once to be scored3 a s positive.) B. Group Two: (1) Patient has not been able to stop drinking when? he wanted t o do so. ( 2 ) Patient has tried to control drinking by allow-.# ing himself to drink only under cer-!i tain circumstances, such a s only ter 5:00 PM, only on weekends, only with other people. (3) Drin ing before breakfast. ( 4 ) Drinkii nonbeverage forms of alcohol, e hair oil, mouthwash, Sterno, etc. C. Group Three: ( 1 ) Arrests for drinking. ( 2 ) Traffic difficulties associated with drinking. ( 3 ) Troubl a t work because of drinking. ( 4 Fighting associated with drinking.

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D. Group Four: (1) Patient thinks he drinks ~ O Omuch. (2) Family objects to his drinking. (3) Loss of friends because of drinking. (4) Other people object to his drinking. (5) Feels guilty about his drinking. Drug Dependence (Excluding ~1coholisrn.~~-This diagnosis is made when any one of the following are present. The drug type is specified according to DSM-IZ. A. History of withdrawal symptoms. B. Hospitalization for drug abuse err its complications. t'. Indiscriminate prolonged use of central nervous system active drugs. Mental Retardation.-This disorder, which has different causes, is described both in terms of intellectual impairment as well as social maladaptation as described in DSM-II. In view of the fact that the social adaptation scales have not b w n standardized to the level of current intelligence tests, only the latter are used in making this diagnosis. The following criteria are used : A. When the I& is available from currently acceptable tests, the categories of DSM-ZI are used. B. In the absence of I & tests, the following will be accepted as evidence of suspected mental retardati(?:! : ( 1) Despite continued effort an individual fails the same grade two years in succession, or (2) despite continued effort the individual fails to pass the sixth grade by the time he is 16 years old. (Caution should be used in making the diagnosis of mental retardation in the presence of another psychiatric illness, eg, schizophrenia, "erere affective disorders, antisocial Dwl'snnalitydisorder.) Organic Brain Syndrome.47.48This diagnosis is made when either crikrion A or criterion B is present. A. TWO of the following manifestations must be present. (In the Presence of muteness the diagnosis
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must be deferred.) (1) Impairment of orientation. (2) Impairment of memory. (3) Deterioration of other intellectual functions. B. This diagnosis is also made if the patient has a t least one manifestation ( A ) in addition to a known probable cause for organic brain syndrome. Horn~sexuality.~~-~~-For a diagnosis of homosexuality, A through C are required. A. This diagnosis is made when there are persistent homosexual experiences beyond age 18 (equivalent to Kinsey rating 3 to 6). B. Patients who fulfill the criteria for transsexualism are excluded. C. Patients who perform homosexual activity only when incarcerated for a period of a t least one year without access to members of the opposite sex are excluded. Transsexualisrn.J3-5-n order to receive a "definite" diagnosis of transsexualism, a t least four of the five following manifestations must be present with a t least one manifestation occurring prior to age 12. A diagnosis of "probable" transsexualism is made when three of the following manifestations are present with a t least one occurring prior to age 12. A. A persistent desire to belong to the opposite sex, with a sense of having been born into the wrong sex. B. A strong desire to resemble physically the opposite sex by any available means, eg, manner of dress, behavior, hormone therapy, and surgery. C. A strong desire to be accepted by the community as a member of the opposite sex. D. A negative feeling about the patient's external genitalia (breasts are included) including attempts a t mutilation and a desire for surgery. E. A negative feeling towards heterosexual activity and a persistent feeling that physical attraction to members of the same sex is not a homosexual orientation. ar Anorexia N e r v ~ s a . ~ ~ - ~ - F o

diagnosis of anorexia nervosa, A through E are required. A. Age of onset prior to 25. B. Anorexia with accompanying weight loss of a t least 25% of original body weight. C. A distorted, implacable attitude towards,, eating, food, or weight that overMea hunger, admonitions, reassurance and threats ; eg, (1) Denial of illness with a failure to recognize nutritional needs, (2) apparent enjoyment in losing weight with overt manifestation that food refusal is a pleasurable indulgence, (3) a desired body image of extreme thinness with overt evidence that it is rewarding to .the patient to achieve and maintain this state, and (4) unusual hoarding or handling of food. D. No known medical illness that could account for the anorexia and weight loss. E. No other known psychiatric disorder with particular reference to primary affective disorders, schizophrenia, obsessive-compulsive and phobic neurosis. (The assumption is made that even though it may appear phobic or obsessional, food refusal alone is not sufficient to qualify for obsessive-compulsive or phobic disease.) F. At least two of the following manifestations. (1) Amenorrhea. (2) Lanugo. (3) Bradycardia (persistent resting pulse of 60 or less) (4) Periods of overactivity. (5) Episodes of bulimia. ( 6 ) Vomiting (may be self-induced). Undiagnosed Psychiatric Illness. -Some patients cannot receive a diagnosis for one or more reasons. Among the more common problems that cause a patient to be considered undiagnosed are the following : ( 1) cases in which only one illness is suspected but symptoms are minimal. (2) Cases in which more than one psychiatric illness is suspected but symptoms are not sufficient to meet the criteria of any of the possibilities. (3) Cases in which symptoms suggest two or more disorders but in an atypical or confusing
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manner. ( 4 ) Cases i n which t h e chronology of important symptom clusters cannot be determined. (5) Cases i n which it is impossible to obtain t h e necessary history t o establish a definitive diagnosis. Comment There a r e many diagnoses listed in DSM-11 not considered in this communication because sumcient clinical data f o r even limited diagnostic validation are not available. A recent attempt t o delineate passive-aggressive personality disorder as a separate e n t i t y based on crosssectional and longitudinal data brings t o focus some of t h e problems in diagnostic validation. As the investigators of t h a t study suggested, f u r t h e r studies are needed before t h e validity of t h a t syndrome

References

is
Finally, t h e criteria presented i n this report a r e "minimal" i n two senses : First, all diagnostic criteria a r e tentative in t h e sense t h a t they change and become more precise with new data. Second, we have made no effort t o subclassify these illnesses. ( F o r example, we have presented criteria t o define primary affective disorders, unipolar type, without suggestions f o r f u r t h e r subdivision into forms of early and late onset, psychotic o r nonpsychotic forms, agitated o r retarded forms, and so forth. It i s clear t h a t primary affective disorder, unipolar type, is a reasonable major classification. The d a t a to support i t s subclassification are still tentative.) We and other investigators will continue to work toward modification and subclassification. W h a t we now present i s our synthesis of existing information, a synthesis based on data rather than opinion o r tradition. We hope t h a t such a presentation will help to promote useful communication among investigators.
This study was supported in part by Public Health Service grants MH 18002. MH 09247, MH 06804, and MH 07081 from the National Institute of Mental Health.

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low-up. Acta Psychiat Neurol Scani 33 :377-399, 1958. 18. Eitinger L, Laane CV, Lan e feldt G: The ~ r o m o s t i cvalue of clinical picture &d the therapeutic value of physical treatment in schizo phrenia and the schizophreniforn states. Acta Psuchiat Neurol Scand 33 33-53, 1958. 19. Stephens JH, Astrup C, Man. grum JC: Prognostic factors in re covered and deteriorated schizophre nics. Amer J Psychiat 122:1116-1120 1966. 20. Vaillant GE: The prediction oj recovery in schizo hrenia. J Nerz Ment Dis 135:534-54!, 1962. 21. Vaillant GE: Prospective predic. tion of schizophrenic remission. Arcli Gen Psychiat 11:509-518, 1964. 22. Clayton PJ, Rodin L, Winoku~ G: Family history studies: 111. Schizoaffective disorder, clinical and genetic factors including a one to two-yeax follow-up. C o m p Psychiat 9:31-49 1968. 23. Bleuler E: Dementia Praecoz 07 the Group of Schizophrenics. J. Zinkin, (trans), New York, International Universities Press, 1950. 24. Langfeldt G: The prognosis in schizophrenia. Acta Psychiat Neuroi Scand 110 (suppl) :1-66, 1956. 25. Langfeldt G: Diagnosis and prognosis of schizophrenia. Proc Royal Soc Med 53:1047-1052, 1960. 26. Fish F: A guide to the Leonhard classification of chronic schizophrenia. Psychiat Quart 38:438-450, 1964. 27. Wender PH: The role of geneti ics in the etiology of the schizophrenias. Amer J Orthopaychiat 39:447-458, 1969. 28. Wender PH, Rosenthal D, Kety S: A psychiatric assessment of the adoptive parents of schizo hrenics in khr Rosenthal D, Kety S reds!: Transmission of Schizophrenza. Oxford, England, Pergamon Press, 1968. 29. Heston L: Psychiatric disorder8 in foster home reared children of schizophrenic mothers. Brit J Psychiat 112:819-825,1966. 30. Heston L: The genetics of schizophrenic and schizoid disease. Scienoe 167:249-256, 1970. 31. Fish F : Schizophrenia. Balti-, more, Williams & Wilkins Co, 1962. 32. Wheeler EO, White PD, Reed EW, .et al: Neurocirculatory asthenia (anxlety neurosis, effort syndrome neurasthenia). JAMA 142:878-888, 1950. 33. Goodwin DW, Guze SB, Robins E : Follow-up studies in obsessional neurosis. Arch Gen Psychiat 20:182. 187, 1969. 34. Pollitt J: Natural history of obsessional states: A study of 150 ca Brit Med J 1:194-198, 1957.

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4 :

D: The epidemiology of common fears


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